Carrollton First United Methodist Church Medical Release/Photo Permission Form

Carrollton First United Methodist Church Medical Release/Photo Permission Form
Student's Name *

First Name Middle Name Last Name
Current Year in School *
Male Female Prefer not to answer
Student's Email
example@example.com
Student's Phone Number
Please enter a valid phone number.
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Medical Insurance Company
Policy #
Parent/Guardian Name *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Emergency Contact *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Alternate Phone Number (if applicable)
Please enter a valid phone number.
Family Physician
Office Phone Number
Please enter a valid phone number.
Dentist
Office Phone Number
Please enter a valid phone number.
Medical History

If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification in writing and return to the church office.
Please select the following areas of concern for this student. If necessary, include additional details in space provided at the end of the form.
For your child's safety and our knowledge, is your student a ---

good swimmer fair swimmer non-swimmer
Does your child have allergies to

pollens medications food insect bites Other
If so, please list their specific allergy/allergies
Does your child suffer from, or has ever experienced, or is being treated currently for any of the following:

asthma epilepsy/seizure disorder heart trouble diabetes frequently upset stomach physical handicap
Date of Last Tetanus Shot

Month Day Year
Date
Does your child wear:

glasses contact lenses
Medications Currently Taking (list all, even vitamins)
Please list and explain any major illnesses the child experienced during the last year:
Should this child's activities be restricted for any reason? Please explain:
Additional Information/Instructions Regarding Child/Youth:
For your information, we expect each student to conform to these rules of conduct:
1. No possession or use of alcohol, drugs, or tobacco.
2. No students are permitted to drive on church events.
3. No fighting, weapons, fireworks, lighters, or explosives are allowed.
4. No offensive or immodest clothing is to be worn.
5. No boys are to be in girls' sleeping quarters and no girls in boys' sleeping quarters.
6. Participation with the group is expected.
7. Respect property.
8. Respect one another, staff, and adult leaders.
9. Respect and comply with event schedules.
Students who fail to comply with these expectations may be sent home at their parent's expense.

Activities may include, but are not limited to: cookouts, canoeing, swimming, basketball, roller skating, rollerblading, games in the park, soccer, bowling, ice skating, volleyball, softball, baseball, camping, downhill skiing, snowboarding, hiking, biking, concerts, Bible studies, miniature golf, hayrides. Note: if you desire to limit your child's participation in any event, please submit your wishes in writing to the Church prior to that event.
Student's Name Here has my permission to attend all activities sponsored by Carrollton First United Methodist Church. I, Parent/Guardian give permission for my child, Student's Name Here to ride in a vehicle driven by an authorized adult to any Carrollton First UMC outings and events during the current year.
This consent form gives permission to seek whatever medical attention is deemed necessary, and releases Carrollton First United Methodist Church and its staff of any liability against personal losses of named child.
I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to the person or property that may occur during the course of my/our child's involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising form the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member.
Parent/Guardian Signature *

Clear
Date

Month Day Year
Date
Photo Permission
I give permission for my child's photo to be taken by camera or video and used in church publications and on the church website.
Parent/Guardian Signature *

Clear
Date

Month Day Year
Date
Should be Empty:

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Carrollton First United Methodist Church Medical Release/Photo Permission Form

Medical History

Photo Permission